Health inspection·July 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the nutrition care plan was implemented for one of 18 residents reviewed for care plans. (Resident 6) This failure resulted in Resident 6 not receiving foods listed in the care plan, which may have led to the resident's continued gradual weight loss. Cross reference F692, F800 Findings: Resident 6 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, Oropharyngeal Phase (swallowing problem occurring in the mouth and/or throat) according to the admission Record. A review of Resident 6's Minimum Data Set (MDS-tool that measures health status), dated 6/10/23 indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. During a dining room observation on 7/24/23 at 1:00 P.M., Resident 6 was having lunch. Resident 6 was observed eating the soup and stated he did not want the rest of the meal. Resident 6 requested a strawberry yogurt from staff. An interview was conducted on 7/25/23, at 10:31 A.M., with Certified Nurse Assistant (CNA) 22. CNA 22 stated she had not seen any snacks provided to residents. During an interview on 7/25/23, at 10:46 A.M., with Resident 6, Resident 6 stated he had lost 30 lb (pounds) since he had been ill and lost 10 lb in the facility. Resident 6 stated snacks have not been offered and food preferences have not been updated. Resident 6 further stated no menu or alternates have been provided to him. There was no menu or snack list observed in Resident 6's room. A review of Resident 6's care plan, dated 6/28/23 indicated, snacks and an intervention dated 7/19/23 indicated, RD to meet with resident weekly+to update food preferences, offer alternatives, encourage greater intakes. The care plan further indicated an intervention dated 7/25/23, RD will check with resident 1x daily . During an interview and concurrent record review on 7/26/23, at 10:44 A.M., with the Registered Dietitian (RD), the RD stated she checked in with the resident but there was no documentation regarding Resident 6's intake of snacks or the supplement. The RD further stated there was no RD coverage on the weekends and therefore Resident 6 will not be checked daily according to the care plan. The RD acknowledged she could not verify whether the nutrition care plan interventions for Resident 6 were consistently implemented, but they should have been carried out as documented. During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol, dated 2023, the P&P indicated, .A care plan is to be developed stating the problems, the goal, and the approaches, interventions to accomplish the goal .The facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate nutrition was provided for one of two sampled residents with severe weight loss in less than one month. (Resident 6) Residents Affected - Few This failure had the potential to result in Resident 6's further unintentional and unplanned weight loss. Cross reference F656, F800 Findings: During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated , . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association) . During a review of professional reference titled, Involuntary Weight Loss can lead to Muscle Wasting . Depression and an increased rate of Disease Complications (www.aafp.org/afp American Family Physician). Dated 2/15/02, indicated, . Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost five percent of their body weight in one month were found to be four times more likely to die within one year . During a review of professional reference titled, The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines dated 2007-2009, indicated, . The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT) . Resident 6 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, Oropharyngeal Phase (swallowing problem occurring in the mouth and/or throat) according to the admission Record. A review of Resident 6's Minimum Data Set (MDS-tool that measures health status), dated 6/10/23 indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. During an interview on 7/25/23, at 10:46 A.M., with Resident 6, Resident 6 stated he had lost 30 lb (pounds) since he had been ill and lost 10 lb in the facility. Resident 6 stated snacks have not been offered and food preferences have not been updated. Resident 6 was observed with boost (a nutritional supplement) at the bedside. Resident 6 stated he received Boost every three days and will request for boost daily from staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a review of Resident 6's weight history on 7/26/23, the weight record in the electronic medical record indicated: Level of Harm - Minimal harm or potential for actual harm 202 lb on 6/28/23 Residents Affected - Few 200.6 lb on 7/1/23 188.5 lb on 7/8/23 175 lb on 7/15/23 172.4 lb on 7/23/23 During a record review on 7/25/23 of the facility's Nutrition Assessment signed by the RD on 7/6/23, the assessment indicated Despite poor po intakes resident accepts boost plus at times, will recommend adding this routinely bid to lunch and dinner meals. In addition, Resident 6's physician's order dated 7/7/23 indicated, Boost plus with meals BID, and on 7/14/23 the physician's order indicated, Boost bid with meals. During a concurrent interview and record review on 7/26/23, at 9:31A.M., with the Registered Dietitian (RD), the RD stated she did not specify which meal Resident 6 was to receive the boost and was unsure which meal tray it was sent to. The RD further acknowledged there was no record of the amount of boost Resident 6 consumed daily. The RD stated it was important to know how much boost was consumed to competently calculate calories for the resident. The RD further stated Resident's 6 weight loss was unintentional. During an interview of the facility's Medical Director (MD) on 7/27/23 at 11:08 A.M., the MD stated all efforts to improve nutrition should be documented. The MD further stated if interventions were carried out as written as an order and care plan, interventions should make a positive difference in a resident's weight status. During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol, dated 2023, the P&P indicated, .The facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions .Calculate energy, protein, and fluid needs using perimeters as in the initial assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, interviews, and record reviews the facility failed to ensure effective dietetic systems related to food and nutrition services were executed according to facility policy and standards of practice when: 1. A resident's (Resident 6), nutrition care plan was not carried out, and experienced unintentional weight loss. 2. Kitchen staff were not trained in day-to-day food safety and sanitation practices. 3. Residents' meals were not served at palatable temperatures according to policy. 4. Expired foods, dirty dishes, and dirty equipment were found in the kitchen. 5. Kitchen equipment was not maintained for proper operation. These deficient practices led to a resident to experience unintentional weight loss, and exposed 81 residents to unsafe and unsanitary food practices, which may have further compromised their nutrition status. Cross reference F656, F692, F802, F804, F812, and F908 Findings: According to the Federal FDA Food Code section 2-103.11, titled Person in Charge (PIC), .The PERSON IN CHARGE shall ensure that .(H) EMPLOYEES are using proper methods to rapidly cool time/temperature control for safety foods that are not held hot or are not for consumption within 4 hours, through daily oversight of the employees routine monitoring of FOOD temperatures during cooling; .the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment . 1. During a record review of Resident 6's care plan, dated 6/28/23 indicated, snacks, and an intervention dated 7/19/23 indicated, RD to meet with resident weekly+to update food preferences, offer alternatives, encourage greater intakes. The care plan further indicated an intervention dated 7/25/23, RD will check with resident 1x daily . During a record review of Resident 6's weight history on 7/26/23, the weight record in the electronic medical record indicated: 202 lb on 6/28/23, 200.6 lb on 7/1/23, 188.5 lb on 7/8/23, 175 lb on 7/15/23, and 172.4 lb on 7/23/23. A record review on 7/25/23, at 11:26 A.M. of the facility's Nutrition Assessment, signed 7/6/23, indicated, Despite poor po intakes resident accepts boost plus at times, will recommend adding this routinely bid to lunch and dinner meals. In addition, Resident 6's physician's order dated 7/7/23 indicated, Boost plus with meals BID, and on 7/14/23 the physician's order indicated, Boost bid with meals. During a concurrent interview and record review on 7/26/23, at 9:31A.M., with the Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Dietitian (RD), the RD stated she did not specify which meal Resident 6 was to receive the boost and was unsure which meal tray it was sent to. The RD further acknowledged there was no record of the amount of boost Resident 6 consumed daily. The RD stated it was important to know how much boost was consumed to competently calculate calories for the resident. During an interview and concurrent record review on 7/26/23, at 10:44 A.M., with the Registered Dietitian (RD), the RD stated she checked in with the resident but there was no documentation regarding Resident 6's intake of snacks or the supplement. The RD further stated there was no RD coverage on the weekends and therefore Resident 6 will not be checked daily according to the care plan. The RD acknowledged she could not verify whether the nutrition care plan interventions for Resident 6 were consistently implemented, but they should have been carried out as documented. The RD further stated Resident's 6 weight loss was unintentional. 2. During the kitchen observation and interview on 7/24/23 at 4:20 P.M. with a Diet Aide (DA) 2, a Certified Nurse Assistant (CNA) 22 translated in Spanish the responses of DA 2 about the manual three compartment sink. DA 2 stated if the dishwasher was broken, a manual wash would be done at the three-compartment sink. DA 2 stated she would check the water temperature with the thermometer and the sink water temperatures should be 120 degrees Fahrenheit (F) in all three sinks. DA 2 was not able to verbalize the entire process for the 3 compartment sink manual dishwashing. DA 2 stated she was trained by another Diet Aide on the process. During an interview on 7/26/23, at 10:44 A.M. with the Registered Dietitian (RD), the RD stated she took over employee monitoring to improve their tasks. The RD stated the dietary staff were informed of and trained on identified concerns in the kitchen but there was no in-service record pertaining to manual dishwashing or the cool down process. The facility's policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023 was reviewed. The P&P indicated supplies needed and five steps to complete a manual dishwashing procedure. 3. During a breakfast meal test tray process on 7/25/23 at 7:40 A.M., the DD and the Consultant Dietary Manager (CDM) took temperatures and tasted a regular diet meal tray and pureed diet meal tray for acceptable temperature and palatability. The test tray for regular and pureed meals included a Spanish egg omelet with salsa on top, a carton of milk, cranberry juice and wheat toast. The temperature for the eggs in the regular tray was 142ºF. The puree eggs temperature was 119ºF. The DD acknowledged the regular omelent eggs temperature and puree omelet temperature, then stated they could be warmer. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, .3. The food will be served on trayline at the recommended temperature .Meat 160ºF-170ºF .Scrambled eggs 150ºF-170º . 4. During a concurrent observation and interview of kitchen conducted on 7/24/23 at 12:00 P.M. with the DD, an outside freezer was observed with cases of ice cream cups. The freezer was against a short brick wall under the sun. The ice cream cups were not frozen and soft. The freezer door inner gasket was observed with dark brown and black stains and was not clean. According to the DD, the freezer was kept outside because there was not enough voltage inside the kitchen. During a dining room lunch observation on 7/24/23, at 1:00 P.M., one resident was observed with a sherbet ice cream on the tray which was almost 100 percent melted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, .7. The goal is to serve cold food cold . During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All .equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams . 5. During the initial kitchen tour on 7/24/23 at 10:16 A.M. with the Registered Dietitian (RD) and the Dietary of Dietary (DD), a cord connected to the tray line steam table was observed hanging out of the socket. The RD and the DD stated the cord should not be exposed because it may cause damage and it was a safety risk. There was a large air vent with black and gray dirt and lint contaminants observed blowing air directly above a clean dish drying rack. The RD and DD further acknowledged the dirty vent above the clean dish rack and stated it should be clean. During an interview with the Facility Administrator (ADMIN) on 7/26/23 at 2:54 P.M regarding kitchen operations, the ADMIN stated it was her expectation that the DD train and educate the kitchen staff on correct kitchen operations, updated the staff with current changes in duties, and took input from the RD and the residents when needed to improve the department operations. According to the 2022 Federal FDA Food Code, section 4-501.11, titled Good Repair and Proper Adjustment, Proper maintenance of equipment .helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure kitchen staff received the competencies and training needed to perform their job duties when: Residents Affected - Many 1. A [NAME] could describe the cool down process for cooked foods, and 2. A Diet Aide could not describe the correct temperatures of the three-compartment sink for manual dish washing These failures placed residents at risk of cross contamination and acquiring food-borne illnesses. Findings: 1. During an interview on 7/24/23 at 9:40 A.M. with [NAME] (CK 1) and the Director of Dietary (DD), CK 1 stated there was no cool down process for foods, but only for meats. CK 1 stated if they cooled meats to serve later, they would cool it for a couple of hours, label it, date it then place it in the refrigerator. CK 1 further stated it had been a while since he received training on the cool down process. The DD acknowledged CK 1 did not correctly verbalize the cool down process for cooked foods. According to the 2022 Federal FDA Food Code, section 3-501.14 titled Cooling, .Time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms the Food Code provision for cooling provides for cooling from 135ºF to 41°F or 45°F in 6 hours, with cooling from 135ºF to 70°F in 2 hours. The 6-hour cooling parameter, with an initial 2-hour rapid cool, allows for greater flexibility in meeting the Code. The initial 2-hour cool is a critical element of this cooling process . 2. During the kitchen observation on 7/24/23, at 4:20 P.M., Diet Aide (DA) 2 was interviewed. A Certified Nurse Assistant (CNA) 22 translated in Spanish the responses of DA 2 regarding the manual three compartment sink temperatures. DA 2 stated if the dishwasher was broken, a manual wash would be done at the three-compartment sink. DA 2 stated she would check the water temperature with the thermometer and the sink water temperatures should be 120 degrees Fahrenheit (F) in all three sinks. DA 2 was not able to verbalize the entire process for the 3 compartment sink manual dishwashing. DA 2 stated she was trained by another Diet Aide on the process. During an interview on 7/26/23, at 10:44 A.M. with the Registered Dietitian (RD), the RD stated she took over employee monitoring to improve on their tasks. The RD stated the dietary staff were informed of identified concerns in the kitchen for training but there was no in-service record pertaining to manual dishwashing or the cool down process. According to the 2022 Federal Food Code section 4-603.16, titled Rinsing Procedures, .(A) Use of a distinct, separate water rinse after washing and before sanitizing if using: A 3-compartment sink .A 3-step washing, rinsing, and sanitizing procedure in a warewashing system . According to the 2022 Federal Food Code section 4-501.19, titled Manual Warewashing Equipment, Wash Solution Temperature, The wash solution temperature required in the Code is essential for removing organic matter . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete According to the 2022 Federal Food Code section 4-501.111, titled Manual Warewashing Equipment, Hot Water 2Sanitization Temperatures, If the temperature during the hot water sanitizing step is less than 171 Fahrenheit (F), sanitization will not be achieved. As a result, pathogenic organisms may survive and be subsequently transferred from utensils to food. The facility's policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023 was reviewed. The P&P indicated supplies needed and five steps to complete a manual dishwashing procedure. Event ID: Facility ID: 055632 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standard of practice when: Residents Affected - Many 1. A tray with fourteen small glasses of milk and four glasses of juice each dated 7/14/23, were on the shelf for use in the walk-in refrigerator. 2. The kitchen's clean dish storage area had dirty serving utensils and food items stored on them. 3. The ceiling vent was full of grayish-black dust. 4. The facility did not use a cool down process for ambient temperature prepared foods. 5. An ice cream freezer door gasket had dark brown and black stains and was not clean. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. During an initial kitchen tour on 7/24/23 at 8:50 A.M. conducted with the facility's Director of Dietary (DD) and Lead [NAME] (LCK), inside the walk-in refrigerator there was a tray with twelve small 4 ounce glasses of milk covered with plastic wrap on top and other beverages next to them. The milk and other beverages were dated 7/18/23. The DD acknowledged all the cups of milk and beverages were outdated and should have been discarded. The facility's policy and procedure (P&P) titled, Refrigerator and Freezer, dated 2023, the P&P indicated, .3. Check all foods at least weekly, being mindful of expiration and use by dates. 2. During the kitchen tour on 7/24/23 at 8:50 A.M., the clean area with containers filled with serving utensils was observed with a water bottle, Starbucks coffee cup and a cleaning spray on the counter. A serving scoop inside the clean container was observed to have a small brown debris. Diet Aide 2 (DA 2) stated both the water bottle and coffee belonged to her and should have been stored outside of the kitchen, not in the clean area. Another clean area at the bottom of the microwave counter were clean, small plastic glasses inside a container. A dirty tray was observed on top of the container. DA 2 confirmed that the tray was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 dirty. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/24/23, at 8:50 A.M. with the DD, the DD stated it was everyone's responsibility to check the clean area. Residents Affected - Many Beside the microwave a beverage/juice machine dispenser was observed. The DD stated the aides cleaned the nozzles of the dispenser daily. The DD further stated there was no cleaning log for the nozzles. According to the FDA Food Code, 1022 4-601.11, .it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas . 3. During the initial kitchen tour on 7/24/23, at 10:16 A.M. with the RD and the DD, the ceiling vent above the steam table was observed with full of grayish-black dust. The RD and the DD stated the ceiling vent should be clean. The Director of Maintenance (DM) was interviewed on 7/26/23, at 3:41 P.M. The DM stated there was no maintenance repair request or binder for the kitchen maintenance issues and there was no facility policy maintenance service. The DM further stated the ceiling vent should have been cleaned. According to the Federal FDA Food Code 2022, section 6-501.12, titled Cleaning, Frequency and Restrictions, .(A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . During a review of the facility's P&P titled, Hoods, Filters, and Vents dated 2023, the P&P indicated, Vents must be free of dust and dirt . 4. During an interview on 7/24/23 at 9:20 A.M. with [NAME] 1 (CK 1) regarding the cool down process of food, CK 1 stated meats were the only foods needing cool down for a couple of hours, then date and label it. A follow up interview and concurrent record review was conducted with the LCK. The LCK stated they did not need to conduct any cool down process because food was served right out of the oven. The LCK presented a cool down log dated 2022. The LCK was not able to provide cool down process for the tuna salad in the walk-in refrigerator. During an interview on 7/24/23, at 4:03 P.M. with [NAME] 2 (CK 2) about cool down of ambient temperature foods, CK 2 stated he did not write the temps on a log when preparing tuna salad. During a review of the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, the P&P indicated, .Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. 5. During a concurrent observation and interview were conducted on 7/24/23 at 12:00 P.M. with the DD, a freezer outside the kitchen was observed during the kitchen tour. The freezer was against a short brick wall under the sun. Inside the freezer were cups of ice cream which were not frozen. In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many addition, the ice cream freezer door gasket was observed with dark brown and black stains and was not clean. According to the DD, the freezer was kept outside because there was not enough voltage inside the kitchen. During a dining room observation on 7/24/23, at 1:00 P.M., one resident was observed with a sherbet ice cream on the tray which was almost melted. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, .7. The goal is to serve cold food cold . During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All .equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review, the facility failed to accurately record medications given for one of one resident reviewed for IV medication administration. This failure had the potential for harm, leading to missed or additional medication being given. Findings: The admission Summary for Resident 217 indicated that the Resident was admitted on [DATE], with health problems that included: urinary tract infection (UTI). The Physician admitting orders included: Zosyn (an antibiotic) 3.375 grams , via IV (given through a soft flexible tube inserted in a vein), four times a day for nephrolithiasis (kidney stones) with UTI until 7/29/23. The physician order included administration times of 1 A.M., 7 A.M., 1 P.M. and 7 P.M. On 7/26/23, at 11:19 A.M. a concurrent record review and interview was held with the Director of Staff Development (DSD), the Director of Nursing (DON) and the Infection Preventionist Nurse (IP). The e-MAR (the electronic health record for Medication Administration Record) was reviewed, and out of 42 opportunities for Zosyn administration, (the RN administering the medication signs that it was given) there were 10 missed opportunities when the RN did not record the administration of the IV antibiotic. The IP and DON stated that inaccurate documentation could lead to inadequate or overdosing of a medication, harming the patient. The DON stated that education will be completed with all RN staff administering IV medications, and that the problem has been added to QAPI. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when: Residents Affected - Few 1. A Certified Nursing Assistant (CNA 3) did not disinfect the vital signs machine between each resident use. 2. The Business Office Manager (BOM) did not perform hand hygiene when delivering meal trays to the residents. This failure had the potential to spread infections between residents. Findings: 1. On 7/25/23 at 2:58 P.M.,an observation was conducted with CNA 3. CNA 3 went to residents' room and took the vital signs of the two residents. CNA 3 then exited the first room and went to another resident's room without sanitizing the vital sign machine. On 7/25/23 at 3:01 P.M., an interview was conducted with CNA 3. CNA 3 stated she had nine residents and had already took their vital signs. CNA 3 stated the process was the vital sign machine should be sanitized between each resident use. CNA 3 stated she did not wipe the vital sign machine after taking each resident's vital signs. CNA 3 stated she should have sanitized after each use to prevent infection and transmission of disease. On 7/27/23 at 9:37 A.M., an interview was conducted with the Infection Preventionist. The IP stated the expectation was for the staff to sanitize the critical items like the vital sign machine to prevent transmission of infection. On 7/27/23 at 2:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was the staff should have sanitized the vital sign machine in between resident use to prevent transmission of infection. A review of the facility's undated Infection Control policy, indicated, It is the policy of this facility to provide supplies and equipment that are adequately cleaned and disinfected .1. Supplies and equipment will be cleaned immediately after use . Findings: 2. A Meal Tray delivery was observed on 7/24/23 at 12:40 PM. The Business Office Manger (BOM) was seen delivering a meal tray to a room, returning to the cart, retrieving another tray, and delivering to the other resident in the room. Hand Hygiene (HH- the process of rubbing the hands with Alcohol Based Sanitizing Liquid until dry) was not observed. The BOM returned to the cart, retrieved another tray, and delivered to another resident room. The BOM then performed HH. The BOM retrieved a meal tray from the cart and handed the tray to staff wearing gown, gloves, N95 mask, and face shield, in the doorway of a room. No HH was performed. The BOM then returned to the cart, retrieved a meal tray and handed the meal tray to staff, similarly garbed, in the doorway of another room. No HH was performed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The BOM returned to the cart, retrieved and handed a meal tray to staff in the doorway of the same room. No HH was performed. The BOM returned to the meal cart, retrieved a tray, and handed it to the staff in the doorway of the same room. No HH was performed. The BOM selected another tray from the cart and handed it to staff in the doorway of the room. No HH was performed. The BOM selected another meal tray from the cart and handed it to staff in the doorway of the room. The BOM then performed HH and left the area. On 7/24/23 at 12:49 P.M., The DSD was interviewed. The DSD stated the importance of hand hygiene between delivery of meals to residents was to minimize the risk of infection from one resident, or from high touch surfaces to another resident. The DSD stated the residents are at high risk for infection due to their physical conditions, and staff need to perform adequate infection control practices. The DSD agreed that HH should have been done between meal tray delivery by the BOM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and document reviews, the facility failed to ensure essential kitchen equipment and vents were maintained and operational according to standards of practice and facility policy. Residents Affected - Few This deficient practice had the potential to negatively affect the temperature of hot and cold foods and expose clean dishes to contaminants from a dirty ceiling vent, which could have led to foodborne illness in 81 residents. During the initial kitchen tour on 7/24/23 at 10:16 A.M. with the Registered Dietitian (RD) and the Dietary of Dietary (DD), a cord connected to the tray line steam table was observed hanging out of the socket. The RD and the DD stated the cord should not be exposed because it may cause damage and it was a safety risk. There was a large air vent with black and gray dirt and lint contaminants observed blowing air directly above a clean dish drying rack. The RD and DD further acknowledged the dirty vent above the clean dish rack and stated it should be clean. During a kitchen observation and interview with the DD on 7/24/23 at 11:45 P.M., there was an outdoor freezer with four cases of three ounce ice cream cups inside. The internal thermometer read 20 degrees Fahrenheit (F) and the ice cream cups cartons were melted, bendable, and soft. The DD stated the freezer gaskets should be cleaned and the internal temperature was warmer than usual because the freezer was outside. The DD stated there was not enough voltage inside the kitchen for the ice cream freezer. The DD acknowledged the freezer temperature should be cold enough to freeze ice cream so it was rock solid. During an interview on 7/26/23 at 3:46 PM with the Maintenance Director (DM), and Administrator (ADMIN), the DM stated the facility did not have a policy to repair epuipment in the facility. The DM further stated the facility did not have a binder for departments to document maintenance issues or requests. The ADMIN acknowledged the facility did not have a Maintenance Service policy and procedure but stated they should have one. The DM acknowledged the cord extending from the steam table with exposed red and gray wires, the dirty ceiling vent blowing air above a clean dish rack, and the outdoor ice cream freezer should have been working in proper order and clean without repair issues. According to the 2022 Federal FDA Food Code, section 4-501.11, titled Good Repair and Proper Adjustment, Proper maintenance of equipment .helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures . During a review of the facility's policy and procedure (P&P) titled Refrigerator and Freezer dated 2023, the P&P indicated, Maintaining a clean .freezer can improve the safety and quality of your foods 5. Wipe down gaskets with soapy water .How to keep your .freezer working efficiently: .2. Periodically check door gaskets and replace, if damaged .5. Make sure to maintain clear and adequate airflow on outside condensing units . During a review of the facility's P&P titled, Hoods, Filters, and Vents dated 2023, the P&P indicated, Vents must be free of dust and dirt . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 16 of 16